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Ophtalmia Neonatorum
Flora Abazi, Mirlinda Kubati, Blerim Berisha, Masar Gashi,
Dardan Koinaj and Xhevdet Krasniqi
University Clinical Centre of Kosovo
Republic of Kosovo
1. Introduction
Sexually transmitted infections (STIs) or sexually transmitted diseases (STDs) are common in
low- income countries. Among adult women STIs (excluding HIV) represent around 9% of the
disease burden (World Bank, 1993). This group of disease (Table 1) can lead to infertility,
abortion, neonatal blindness and sometimes death. Furthermore in up to 75% of women STIs
are thought to be asymptomatic, knowing also that vaginal discharge might be caused by non-
sexually transmitted changes in vaginal flora (Sloan et al., 2000; Lush et al., 2003).
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148 Conjunctivitis A Complex and Multifaceted Disorder
2. Etiology
Ophtalmia neonatorum may be caused by microorganisms (infectious etiology), or may be
sterile (non infectious etiology) from chemical irritants (Table 2). Sterile or non infection
ophtalmia neonatorum usually is caused by silver nitrate during prophylaxis of this entity.
As far as infectious etiology concerns there are different bacteria and viruses known to cause
this disease. The most commonly isolated bacteria are: Chlamydia trachomatis and Neisseria
gonorrhoeae; but also: Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus
viridians, Staphylococcus epidermidis, Escherichia coli, Klebsiella pneumoniae, Serratia
marcescens, Proteus, Enterobacter, and Pseudomonas species. Also, Eikenella corrodens has
been reported as a cause of neonatal conjunctivitis (Chhabra et al., 2008). The most
commonly viral cause is Herpes simplex virus (HSV) associated most often with a
generalized herpes simplex infection.
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150 Conjunctivitis A Complex and Multifaceted Disorder
Gonococci have ability to adhere to mucosal epithelial cells and thus can survive, activating
nuclear factor kappa B and activator protein 1, with release of numerous of cytokines and
chemokines (Nauman et al., 1997; Ramsey et al., 1995).
The individual gonococci can invade, replicate intracellulary, and by exocytosis can exit into
the submucosal space (Alexey et al., 2000; Nauman et al., 1999). This lead in a chemotactic
influx of neutrophils resulting in formation of micorabscesses and exudation of purulent
material into lumen of infected tissues. Infection can persist for weeks to months if
untreated because of escape immune response (Gergg et al., 1983; Casey et al., 1986; Shafer
et al., 1986; Kallstrom et al., 1997).
Incubation period of Neisseria gonorrhoeae in eye infection is 2 to 5 days and in some
cases may arise 2 to 3 weeks (Gutman, 2001). Gonococcal conjunctivitis begins as benign
and bilateral with eyelid edema, followed by chemosis. The discharge in the beginning is
sero-sanguineous, later becomes thick and purulent, and may contain also blood. The
infection can spread if treatment is delayed causing complications such as corneal
ulceration and perforation, iridocyclitis, and panophtalmitis. From conjunctiva
gonococcus can spread to cause gonococcus septicemia, arthritis, and other manifestations
(Friendly, 1969).
Staphylococcus aureus can cause ophtalmia neonatorum with purulent discharge. The
treatment consists in topical or systemic antibiotic. In some cases spontaneous resolution can
occur. Also, in Ophtalmia neonatorum are verified methicillin and erythromycin resistant S.
aureus, but serious ophtalmologic infection was not found. In case of erythromycin-resistant
Staphylococcus aureus conjunctivitis is used erythromycin ointment to prevent ophtalmia
neonatorum (Cimolai, 2006; Hedberg et al., 1990).
The group B Streptococcus also may causes ophtalmia neonatorum, and is resolved after 7
days of treatment (Pschl et al., 2002).
Eikenella corrodens is a gram-negative bacillus, fastidious, slow growing, and facultative
anaerobic bacterium. It is found as the normal flora of the human mouth, nasopharynx,
gut, and genitourinary tract. In the last two decades has been recognized as cause of head
and neck infections. It is presented as a cause of neonatal conjunctivitis (Chhabra et al.,
2008).
Neonatal conjunctivitis also is caused from other bacteria such as: Staphylococcus
epidermidis, Streptococcus pneumoniae, Haemophilus species, Klebsiella pneumoniae,
Pseudomonas aeruginosa, and Escherichia coli (Martinez et al., 1993; Olatunji et al., 2007).
Maternal infections
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Ophtalmia Neonatorum 151
Mechanical ventilation
Prematurity
environment
Silver nitrate exposure
3. Clinical findings
The Clinical presentation of Neonatal Conjuctivitis varies depending upon the severity and
the type of infection. The signs and symptoms of ophthalmia neonatorum are similar for
most of the infectious agents (Foster, 1995). Diffuse unilateral or bilateral redness due to
injection of conjuctival vessels is the hallmark. Other common findings incude conjuctival
oedema and discharge. More serious finding include keratitis and orbital celulitis, but also
serious systemic involvement if left untreated (Woods, 2005; Zar, 2005). It is necessary to
make accurate diagnosis in order to begin appropriate treatment which can help to reduce
complications (Table 3).
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152 Conjunctivitis A Complex and Multifaceted Disorder
conjunctiva and cornea. In this case, if untreated or even only topically treated, may worsen
with upper respiratory infection, in severe cases with afebrile pneumonitis usually
presenting at 2 to 20 months of age (Darville, 2005). Approximately 50% of infants with
chlamydial pneumonitis have concurrent conjunctivitis or a recent history of conjunctivitis
(Tarabishy et al., 2008).
Fig. 1. Neonatal conjuctivitis due to chlamydia trachomatis in a five days old infant
Staphylococcus conjunctivitis. Staphylococcus aureus can cause neonatal conjuctivitis with
redness, swollen purulent discharge (Figure 2).
Fig. 2. Neonatal conjuctivitis due to staphylococcus aureus infection in an one week old
infant.
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Ophtalmia Neonatorum 153
4. Diagnosis
Prompt diagnosis is key in establishing proper treatment and minimizing potential serious
complications of disease. An accurate diagnosis of conjunctivitis centers on taking a patient
history to learn when symptoms began, how long the condition has been going on, the
symptoms experienced, and other predisposing factors, such as upper respiratory
complaints, allergies, sexually transmitted diseases, herpes simplex infections, and exposure
to persons with pink eye. It may be helpful to learn whether an aspect of an individual's
occupation may be the cause.
A thorough examination of the globe and periocular structures of a neonate suspected to
have neonatal conjunctivitis is crucial. Corneal involvement should be investigated closely
with and without fluorescein and blue cobalt light. Non-specific signs of neonatal
conjunctivitis include conjunctival injection, tearing, mucopurulent or non-purulent
discharge, chemosis, and eyelid swelling.
Diagnostic tests are usually not indicated unless initial treatment fails or an infection with
gonorrhea or chlamydia is suspected. In such cases, the discharge may be cultured and
stained to determine the organism responsible for causing the condition. Cultures and
smears are relatively painless (Jackson, 2008).
Laboratory studies for suspected infectious etiology should include the following (Table 4
and 5):
Conjunctival scraping, stains for Chlamydia. C. trachomatis is an obligate intracellular
organism and exudates are not adequate for testing so conjunctival specimens for
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154 Conjunctivitis A Complex and Multifaceted Disorder
Chemical -
5. Differential diagnosis
Dacryocystitis
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6. Complications
Complications usually can be divided concerning eye and/or systemic complications.
Ocular complications of neonatal conjunctivitis include pseudomembrane formation,
corneal edema, thickened palpebral conjunctivia, peripheral pannus formation, corneal
opacification, staphyloma, corneal perforation, endophthalmitis, loss of eye, and blindness.
Systemic complication due to Chlamydia infection
Systemic complications of chlamydia conjunctivitis include pneumonitis, otitis, pharyngeal
and rectal colonization. Pneumonia has been reported in 10-20% of infants with chlamydial
conjunctivitis.
Systemic complications due to gonococcal infection
Complications of gonococcal conjunctivitis and subsquent systemic involvement include
arthritis, meningitis, anorectal infection, septicemia, and death.
The complications can be avoided if the proper treatment is initiated at time.
7. Treatment
7.1 Initial therapy
Ophtalmia neonatorum is treated with a broad-spectrum antibiotic e.g. ofloxacin 0.3% qds.
When the microbiological results is present the treatment is based on microbiological cause
(Jackason, 2008).
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156 Conjunctivitis A Complex and Multifaceted Disorder
8. Prophylaxis
8.1 Silver nitrate prophylaxis
German obstetrician Cred', in 1881, has applied 2% silver nitrate solution for prophylaxis of
neonatal ophtalmia, resulting in a reduction of incidence from 7.8% to 0.17%. Thereafter was
started instillation of silver nitrate, based on legislation, in most European countries and
most of North America states in the first half of last century (Schneider, 1984; Crede CSR,
1881; Barasam, 1966). Latest in 1970s approximately half the United States specified 1%
silver nitrate solution as the sole agent (Hammerschlag MR et al., 1908). In the United
Kingdom the procedure has been discontinued, and in Japan and Australia, it was never
used (Shaw EB, 1977). The mother usually can be representative consent of using of Cred's
method in Sweden (Wahlberg V, 1982). The decision for changing of the Wisconsin law in
1980 that tetracycline and erythromycin could be used for prophylaxis against GON was
based on a previous ruling by US Supreme Court (Whittaker N et al., 1981).
The siver nitrate, which by law is instilled within 1 hour after birth, may cause chemical
conjunctivitis pain and visual impairment. The silver nitrate does not prevent all cases of
gonococcal neonatal conjunctivitis. The chemical conjunctivitis caused by silver nitrate may
mask the onset of gonococcus neonatal conjunctivitis (Shaw, 1977; Snowe et al., 1973).
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Ophtalmia Neonatorum 157
Since 1940s, when antibiotics were developed the incidence of gonococcal neonatal
conjunctivitis was decreased dramatically (Butterfield et al., 1981).
Recommendations of the US Centers for Disease Control (CDC) are supported from
American Academy of Pediatrics in 1986 and 1988. According to these recommendations 1%
tetracycline ointment and 0.5% erythromycin ointment were equally acceptable in
preventing of gonococcus ophtalmia neonatorum. Although it was felt that silver nitrate
might be the best agent in areas where the incidence of penicillinase-producing neisseria
gonorrhoeae (PPNG) was appreciable (Peter, 1988).
The CDC's 1989 guidelines on the treatment of sexually transmitted diseases were
unchanged with respect to the prevention of ophthalmia neonatorum (Sexually Transmitted
Diseases Treatment Guidelines, 1989).
In Canada the incidence of PPNG among reported cases of gonorrhea increased from 0.5%
in 1985 to 5.5% in 1989 (Status of penicillinase-producing Neisseria gonorrhoeae in
Canada, 1991).
In 1989 the US Preventive Services Task Force recommended that 1% tetracycline ointment or
0.5% erythromycin ointment have to be applied topically to the eyes of all newborns as soon as
possible after birth and no later than 1 hour after birth (Preventive Services task Forces, 1989).
Silver nitrate was not recommended since it is locally irritating, frequently causing chemical
conjunctivitis, and has limited efficacy in preventing chlamydial ophthalmia neonatorum.
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158 Conjunctivitis A Complex and Multifaceted Disorder
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Modified from Canadian Pediatric Society. Revised Recommandations for the prevention of
neonatal ophtalmia, 2010.
Classification used to determine the strength of the recommendations and the quality of the
evidence on which the recommendations are based.
Category Definition
A Good evidence to support a recommendation for use
B Moderate evidence to support a recommendation for use
C Insufficient evidence to support a recommendation for or against use
D Moderate evidence to support a recommendation against use
E Good evidence to support a recommendation against use
Grade
1 Evidence from at least one properly randomized, controlled trial
Evidence from at least one well-designed clinical trial without
randomization, from cohort or case- controlled analytic studies, preferably
2
from more than one centre, from multiple time series, or from dramatic
results in uncontrolled experiments
Evidence from opinions or respected authorities on the basis of clinical
3
experience, descriptive studies or reports of expert committees
Source. Canadian Pediatric Society. Revised Recommandations for the prevention of neonatal
ophtalmia, 2010.
Table 8.
Tetracycline as silver nitrate does not prevent completely chlamydial ophtalmia neonatorum
(Laga et al., 1988, Canadian Task Force on the Periodic Health Examination, 1992). There
were no significant differences between the rates of chlamydial ophtalmia neonatorum
when prophylaxis with erythromycin was compared with prophylaxis with tetracycline or
silver nitrate. For a modest reduction in chlamydial ophtalmia neonatorum now are
recommended the agents for gonococcal prophylaxis.
Erythromycin 0.5 % is the only antibiotic ointment recommended for use in neonates in each
eye in a single application. Silver nitrate and tetracycline ophthalmic ointment are no longer
manufactured in the United States, bacitracin is not effective, while povidone iodine has not
been studied adequately (Sexually Transmitted Diseases Treatment Guidelines, 2010).
If erythromycin ointment is not available, infants at risk for exposure to N. gonorrhoeae
(especially those born to a mother with untreated gonococcus infection or who has received
no prenatal care) can be administered ceftriaxone 25-50 mg/kg IV or IM, not to exceed 125
mg in a single dose (Sexually Transmitted Diseases Treatment Guidelines, 2010).
The diagnosis and treatment of gonococcal and chlamydial infections in pregnant women
is the best method for preventing neonatal gonococcal and chlamydial disease. Also
preventative measures include proper hand-washing techniques by peripartum and
nursery staff.
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160 Conjunctivitis A Complex and Multifaceted Disorder
9. Prognosis
Chlamydial infection: good - 80% fully recover after one course of treatment.
Viral infection: the ocular prognosis can be poor and the systemic sequelae may be fatal.
Chemical irritation: good - full spontaneous recovery expected after 24-36 hours.
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164 Conjunctivitis A Complex and Multifaceted Disorder
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Conjunctivitis - A Complex and Multifaceted Disorder
Edited by Prof. Zdenek Pelikan
ISBN 978-953-307-750-5
Hard cover, 232 pages
Publisher InTech
Published online 23, November, 2011
Published in print edition November, 2011
This book presents a number of interesting and useful aspects and facets concerning the clinical features,
properties and therapeutical management of this condition. Dr. H. Meja-Lpez et al. present an interesting
survey of the world-wide epidemiologic aspects of infectious conjunctivitis. Dr. U. Ubani evaluates conjunctival
symptoms/signs participating in the clinical features of this disorder. Dr. A. Robles-Contreras et al. discuss
immunologic aspects underlying possibly the conjunctivitis. Dr. Z. Pelikan presents the cytologic and
concentration changes of some mediators and cytokines in the tears accompanying the secondary conjunctival
response induced by the nasal challenge with allergen. Dr. S. Sahoo et al. summarize the treatment and
pharmacologic control of particular clinical forms of conjunctivitis in general practice. Dr. S. Leonardi et al.
explain the basic pharmacologic effects of leukotriene antagonists and their use for the treatment of allergic
conjunctivitis. Dr. J.A. Capriotti et al. evaluate the therapeutical effects of various anti-adenoviral agents on the
acute conjunctivitis caused by adenovirus. Dr. V. Vanzzini-Zago et al. assess the prophylactic use and efficacy
of "povidone-iodium solution", prior the ocular surgery. Dr. F. Abazi et al. present the clinical features,
diagnostic and therapeutical aspects of "neonatal conjunctivitis". Dr. I.A. Chaudhry et al. review the special
sub-form of conjunctivitis, being a part of the "Trachoma". Dr. B. Kwiatkowska and Dr. M. Maliska describe
the clinical, pathophysiologic and immunologic features of conjunctivitis. Dr. S. Naem reviews the conjunctivitis
form caused by Thelazia nematodes, occurring principally in animals.
How to reference
In order to correctly reference this scholarly work, feel free to copy and paste the following:
Flora Abazi, Mirlinda Kubati, Blerim Berisha, Masar Gashi, Dardan Kocinaj and Xhevdet Krasniqi (2011).
Ophtalmia Neonatorum, Conjunctivitis - A Complex and Multifaceted Disorder, Prof. Zdenek Pelikan (Ed.),
ISBN: 978-953-307-750-5, InTech, Available from: http://www.intechopen.com/books/conjunctivitis-a-complex-
and-multifaceted-disorder/ophtalmia-neonatorum
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